Healthcare Provider Details

I. General information

NPI: 1174626840
Provider Name (Legal Business Name): PHUNG T DANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12414 STRATFORD RIDGE CT
SAINT LOUIS MO
63141-6383
US

IV. Provider business mailing address

12414 STRATFORD RIDGE CT
SAINT LOUIS MO
63141-6383
US

V. Phone/Fax

Practice location:
  • Phone: 314-277-2163
  • Fax:
Mailing address:
  • Phone: 314-277-2163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberR5G74
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberR5G74
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: